Treating Swallowing Disorders

Some success stories from the files of the Swallowing Center of the Johns Hopkins Medical Institutions in Baltimore:

-- A man in his mid-50s, self-diagnosed as overstressed and uptight, who suffered recurrent sensations of being unable to swallow and a feeling of something being stuck in his throat.

-- A man who had polio as a child, with a residue of neurological problems affecting swallowing.

-- A middle-aged woman who just thought she was ''a slow eater.'' She would spend hours eating a single meal and never could remember a time when she ate normally. She never mentioned it to a doctor. She never ate anything more substantial than finely ground hamburger.

-- A young man who had suffered recurrent and increasingly debilitating bouts of pneumonia each year since he was a toddler. For more than two decades he was treated -- unsuccessfully -- by pulmonary specialists.

''The patients we really like to see,'' said Dr. William J. Ravich, ''are the ones everyone has missed, but we are able to find the problem and fix it with relative ease.

''Swallowing is something that tends to fall through the cracks,'' said Ravich, who is a gastroenterologist and clinical director of the five-year-old Hopkins Swallowing Center. In fact, it was the perception that the specific problems of swallowing were not considered in diagnosing patients that led Hopkins radiology department chairman Dr. Martin W. Donner, now director of the center, and radiology lecturer Dr. James F. Bosma to get it started.

At first it was an informal group of radiologists, gastroenterologists, neurologists, otolaryngologists and specialists in rehabilitative medicine -- such as speech pathologists -- who were intrigued by the complicated nature of swallowing and the possibility that dysphagia, as disorders of the process are called, are vastly more widespread than had been imagined. Many of the people who are saved from choking by the Heimlich maneuver, Ravich said, may actually have undiagnosed swallowing disorders.

Gradually, as the still unique center began to solve one medical mystery after another, the group became a formal and cohesive team, drawing patients, mostly referred by other physicians or medical centers, from all over the country.

Swallowing disorders fall into four basic categories, specialists have found. First, simplest and probably most common is the narrowing of, or spasms in, the esophagus by the regurgitation of stomach acid -- the kind of thing that causes heartburn, and a more likely cause of heartburn than the popular conception of ''I can't believe I ate the whole thing.'' The stomach is protected against its own acids, but the sphincter at the bottom of the esophagus is supposed to protect that passageway from the contents of the stomach. Acid can lead to scarring of the esophagus, causing the channel to narrow. This may cause food to become stuck on the way down.

A second source of swallowing problems comes when a neurological problem or disease causes the swallowing mechanisms to lose coordination. This is fairly common in the elderly. Some 35 percent of nursing home residents are affected with swallowing impairment, estimates Dr. Martin Donner in a special issue of the journal of Gastrointestinal Radiology. Some may be victims of strokes, others may be suffering from such illnesses as multiple sclerosis or Parkinson's disease.

A third category of swallowing problems involves loss of strength in the muscles, for reasons that are not always clear.

Finally, some people have structural abnormalities.

Ravich and his colleagues estimate that they can help 80 to 90 percent of the approximately 400 patients they see each year.